PAIN

PAIN- What is it?

Cardinal Sign of Inflammation
Mechanical deformation - trauma Chemical irritation released by body

Prostaglandin; Bradykinin; Serotonin; Histamine

Warning Sign
Limits

Function Has psychological/emotional affect

DEFINITION
An unpleasant physical and emotional experience which signifies tissue damage or potential for such damage IASP, 1979

APPRECIATION
Must have knowledge to help athletes understand
May

facilitate return to competition sooner

Acute injury care = Pain control Investigate: Where, What, When

PAIN
Not completely Negative

Necessary for survival

Protective
Warning of impending injury Something is wrong

Modalities
Use to decrease pain Facilitate return to normal function

PATHWAYS
EFFERENT: signals travel away from a central structure, those nerves leaving the CNS; motor signals
AFFERENT: signals travel toward a central structure, ex: brain; sensory signal

NERVES
RECEPTORS
Mechanoreceptors

- pressure and

touch; stretch Thermoreceptors - temperature and change Proprioceptors - muscle length, tension, joint position NOCICEPTORS - PAIN

RECEPTOR NERVE ENDINGS

Meissners Corpuscles (M) pressure, light touch Pacinian Corpuscles (M) deep pressure

(P) joint position, vibration (superficial)

Merkels Cells (M) skin stretch, light touch Ruffini Endings (P) change in position Krausess End Bulbs (T) heat, cold Golgi Tendon Organs (P) length, tension

NOCICEPTORS
Free Nerve Endings - pain impulses are sent to the brain via afferent pathways Brain interprets these signals

Individualized response
Afferent to spinal cord Efferent back to site (motor); Afferent to brain (signal)

Reflex loops

RESPONSIVE TISSUES
Very Sensitive
Skin,

Joint Capsule, Bone (periosteum), Viscera ex: knee study

Sensitive
Subchondral

Bone, Tendons,

Ligaments

RESPONSIVE TISSUES
Limited Sensitivity
Muscle

Insensitive
Cartilage,

Brain Tissue, Disc Nucleus ex: chondromalacia

AFFERENTS
First Order (Primary) Afferents
sensory

nerve that courses outside the

CNS nerve fibers that transmit impulses from the sensory receptors

Subclassified
type

A- myelinated type C- unmyelinated

TYPE A
Categorized by diameter, conduction velocity, origin, and function. Group I, II, IIIA
originate

in deep muscle receptors get progressively slower- less myelinated serve proprioception, kinesthesia, pain from deep tissue damage

TYPE A CHARACTERISTICS
FIBERS
IA IIA IIIA

DIAMETER
12-20 m 6-12 m 1-6 m

CONDUCTION VELOCITY
72-120 s 36-72 s 6-36 s

A - BETA
More superficial - skin receptors Large, myelinated mechanoreceptor Respond to touch and low-intensity mechanical info (vibration) Similar to AII fibers characteristics Play role in Gate Control Theory

A-DELTA
Superficial - skin receptors Large, thinly myelinated Transmit information from warm/cold receptors and free nerve endings
touch,

pressure, thermal

Respond to noxious mechanical stimulus (pinching, etc.) - PAIN

TYPE C AFFERENTS
Muscle and skin receptors Small, slow conducting, unmyelinated Deep: mechano- and noci-; few thermoSuperficial: noci- (50%), thermo- (30%), mechanoMajor player in relay of pain signals

PATHWAYS
Primary afferents synapse with secondary afferent fibers in the dorsal horn of the spinal cord (AIII, beta, delta, C) or travel to medulla in the dorsal column of cord (AI, AII) Many pathways/tracts to carry sensory info to brain - 4 in dorsal spinal cord, 3 ventral

DORSAL COLUMN
*Dorsal column-medial lemniscus pathway
Directly

to medulla; provides proprioception, touch, pressure

Spinocervical- superficial info Postsynaptic dorsal column- mechano, noci Dorsal spinocerebellar- joint receptors

VENTRAL COLUMN
*Spinothalamic tract- 2nd order
afferents classified as wide dynamic range (wide range of stimuli) or nociceptive (pain stimuli) Spinoreticular tract- noxious stimulus; terminate in reticular formation Spinomesencephalic tract- noxious stim; terminate in the periaqueductal gray (midbrain)

HIGHER CENTERS
Medulla Oblongata

Controls autonomic functions

Heart Rate Respiration Vomitting

Connects spinal cord to brain

Higher Centers
Reticular Formation
Located in brain stem Influences alertness, waking, sleeping, and certain reflexes Evokes motor, sensory, and autonomic response to noxious stimuli (rapid response) Important relay in pain control mechanisms

HIGHER CENTERS
Thalamus

Divided into 2 nuclei

Ventral posterior lateral (VPL)

Synapses with fibers from body Synapses with fibers from head and face

Ventral posterior medial (VPM)

Transmits stimuli to somatosensory cortex Transmits stimuli to limbic system

Regulates emotional, autonomic, and endocrine response to pain

HIGHER CENTERS
Periaqueductal Gray
Significant role in pain modulation Relay center for ascending and descending tracts Hormonally controls the release of betaendorphins and other pain reducing chemicals

Endorphins increase pain threshold

PUT IT ALL TOGETHER

Trauma Receptors A-delta C fibers

Afferent Pathway

Cortex Higher centers ouch mommy

Thalamus Reticular Formation PAG

Pain / Spasm Cycle

Pain

Inflammation

Spasm

Pain

PAIN CONTROL: THEORY

Historical

Aristotle: soul is the center of the sensory process; pain located in the heart 19th century: Germans proved that the brain was involved with sensory and motor function Specificity Theory: direct pathway, continuous fiber Pattern Theory: generic nerve transmits code based on sensation; various frequency, pattern

PAIN CONTROL: THEORY

Gate Control Theory

Melzack and Wall 1965 A non-painful stimulus can block the transmission of a painful stimulus Substantia Gelatinosa: dorsal horn; acts as a gate for sensory info; A-beta fibers vs. A-delta and C fibers T Cells: transmission cell that connects sensory nerves to afferent tracts; receives from SG Example: rubbing injury; modalities

PAIN CONTROL: THEORY

Levels Model (Castel, 1979)
Gate theory doesnt cover it all Three levels Involves higher central control Endogenous Opiates

LEVELS THEORY: I
Ascending Influence Pain Control

Similar to Gate Control Theory Large diameter afferents synapse on enkephalin interneurons Release of enkephalins into synapse of nociceptive pathways Enkephalins believed to inhibit release of Substance P

Mechanics

Prohibits synaptic transmission of pain

LEVELS THEORY: II
Descending Influence Pain Control

Higher brain centers modulate synaptic transmission in dorsal horn Stimulus is received in Peri-Aqueductal Gray (PAG) Third-order neurons from Raphe Nucleus are activiated Dorsolateral tract descends from RN and synapse on enkephalin interneurons in lamina II releasing serotonin

Mechanics

Release of enkephalins into 1st and 2nd order afferent nociceptive pathway

LEVELS THEORY: III

Beta-Endorphin Mediated Pain Control

Release of beta-endorphins has analgesic response Hypothalamus is stimulated and synapses with PAG Beta-endorphin released and activates dorsolateral tract

Mechanics

Serotonin released and enkephalin influence

Can be initiated by long term (20-40 min) electrical stimulation (motor level)

High intensity w/ long pulse duration

ASSESSMENT OF PAIN
Subjective finding
better, worse, same comparative Scales, Questionnaires Regardless of situation, must understand that individuals experience and respond to pain differently

CLINICAL PAIN
Local - self defined; symptoms are at the site of the problem Referred - pain in an area of the body not related to the injury Radiating - usually associate with a spinal nerve; seen in a dermatomal pattern Trigger Points - localized area of spasm within a muscle

PAIN